CYNET_SYSTEMS_MAIN_LOGO.gif   PET AND PET CT SKILLS CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) Procedures 1 2 3 4  
Adrenal Scan  
Radionuclide Arteriogram  
Bone Marrow Scan / Whole Body  
Cholescintigraphy (HIDA Scan)  
Cisternogram  
CSF Leak Localization  
Cystography/Ureteral Reflux  
Dacrocystography  
Gallium Scan  
Gastric Emptying  
GE Reflux Scan  
GI Bleed  
Indium 111 WBC Scan  
Injection - Lymphatic  
Liver / Spleen Scan  
Lymphatic Scan / Melanoma  
MUGA Scan  
NVG Rest  
NVT Stress  
Radio Immuno Assay (RIA)  
Shillings  
Thallium/Persantine Stress  
Testicular Scan  
Venogram/Radionuclide  
Ventricular Shunt  
Zevalin Treatment  
Wall Motion  
Parathyroid  
Salivary Glands  
Ventilation / Perfusion  
Perfusion  
Three Phase  
Flow / Function  
With Lasix  
Cancer Survey  
Uptake Scan  
I 123 Scan  
Whole Body  
Limited  
Bone Scan  
Brain Scan  
Liver Spect with Flow  
Renal Scan  
Infarction  
Exercise / Rest - Single  
Exercise / Rest - Multiple  
Thallium/Persantine  
PET / CT  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click)  Age Specific Competencies 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)